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Kotecha K, Tree K, Ziaziaris WA, McKay SC, Wand H, Samra J, Mittal A. Centralization of Pancreaticoduodenectomy: A Systematic Review and Spline Regression Analysis to Recommend Minimum Volume for a Specialist Pancreas Service. Ann Surg 2024; 279:953-960. [PMID: 38258578 DOI: 10.1097/sla.0000000000006208] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2024]
Abstract
OBJECTIVE Through a systematic review and spline curve analysis, to better define the minimum volume threshold for hospitals to perform (pancreaticoduodenectomy) and the high-volume center. BACKGROUND The pancreaticoduodenectomy (PD) is a resource-intensive procedure, with high morbidity and long hospital stays resulting in centralization towards high-volume hospitals; the published definition of high volume remains variable. MATERIALS AND METHODS Following a systematic review of studies comparing PD outcomes across volume groups, semiparametric regression modeling of morbidity (%), mortality (%), length of stay (days), lymph node harvest (number of nodes), and cost ($USD) as continuous variables were performed and fitted as a smoothed function of splines. If this showed a nonlinear association, then a "zero-crossing" technique was used, which produced "first and second derivatives" to identify volume thresholds. RESULTS Our analysis of 33 cohort studies (198,377 patients) showed 55 PDs/year and 43 PDs/year were the threshold value required to achieve the lowest morbidity and highest lymph node harvest, with model estimated df 5.154 ( P <0.001) and 8.254 ( P <0.001), respectively. The threshold value for mortality was ~45 PDs/year (model 9.219 ( P <0.001)), with the lowest mortality value (the optimum value) at ~70 PDs/year (ie, a high-volume center). No significant association was observed for cost ( edf =2, P =0.989) and length of stay ( edf =2.04, P =0.099). CONCLUSIONS There is a significant benefit from the centralization of PD, with 55 PDs/year and 43 PDs/year as the threshold value required to achieve the lowest morbidity and highest lymph node harvest, respectively. To achieve mortality benefit, the minimum procedure threshold is 45 PDs/year, with the lowest and optimum mortality value (ie, a high-volume center) at approximately 70 PDs/year.
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Affiliation(s)
- Krishna Kotecha
- Department of Upper Gastrointestinal Surgery, Royal North Shore Hospital, Sydney, New South Wales, Australia
- Northern Clinical School, The University of Sydney, Sydney, New South Wales, Australia
| | - Kevin Tree
- Department of Upper Gastrointestinal Surgery, Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - William A Ziaziaris
- Department of Upper Gastrointestinal Surgery, Royal North Shore Hospital, Sydney, New South Wales, Australia
- Northern Clinical School, The University of Sydney, Sydney, New South Wales, Australia
| | - Siobhan C McKay
- Department of Upper Gastrointestinal Surgery, Royal North Shore Hospital, Sydney, New South Wales, Australia
- Institute of Cancer and Genomic Science, University of Birmingham, Edgbaston, Birmingham United Kingdom
| | - Handan Wand
- Kirby Institute (formerly National Center in HIV Epidemiology and Clinical Research), University of New South Wales, Sydney, NSW
| | - Jaswinder Samra
- Department of Upper Gastrointestinal Surgery, Royal North Shore Hospital, Sydney, New South Wales, Australia
- Northern Clinical School, The University of Sydney, Sydney, New South Wales, Australia
- Australian Pancreatic Center, Sydney, Australia
| | - Anubhav Mittal
- Department of Upper Gastrointestinal Surgery, Royal North Shore Hospital, Sydney, New South Wales, Australia
- Northern Clinical School, The University of Sydney, Sydney, New South Wales, Australia
- Australian Pancreatic Center, Sydney, Australia
- University of Notre Dame, Sydney
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Lei K, Wang J, Wang X, Wang H, Hu R, Zhang H, Xu W, Xu J, You K, Liu Z. Extended lymphadenectomy based on the TRIANGLE for pancreatic head cancer: a single-center experience. Langenbecks Arch Surg 2024; 409:54. [PMID: 38321184 DOI: 10.1007/s00423-024-03245-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Accepted: 01/29/2024] [Indexed: 02/08/2024]
Abstract
BACKGROUND This study was to compare the safety and efficacy of different lymphadenectomy methods in patients with pancreatic head cancer undergoing pancreaticoduodenectomy (PD). MATERIAL AND METHODS A total of 150 patients were included in this study. Patients were divided into Group A (n = 79), Group B (n = 44), and Group C (n = 27) according to the different lymphadenectomy methods. The clinical endpoint was time to progression (TTP) and overall survival (OS). Postoperative complications of different lymphadenectomy methods were compared respectively. TTP and OS of the three groups were compared by Kaplan-Meier curves. RESULTS There were no significant differences between the three groups in operative time (P = 0.300), death in the hospital (P = 0.253), postoperative hemorrhage (P = 0.863), postoperative pancreatic fistula (POPF) B/C (P = 0.306), bile leakage (P = 0.215), intestinal fistula (P = 0.177), lymphatic leakage (P = 0.267), delayed gastric emptying [(DGE) (P = 0.283)], ICU stay (P = 0.506), and postoperative hospital stay [(PHS) (P = 0.810)]. Median TTP in Groups B and C was significantly longer than in Group A (log-rank test, A vs B: P = 0.0005, A vs C: P = 0.0001). Median OS between the three groups has no statistical difference (P = 0.1546). CONCLUSIONS Extended lymphadenectomy methods based on the TRIANGLE do not increase perioperative complications significantly and can effectively delay tumor progression in patients with pancreatic head cancer.
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Affiliation(s)
- Kai Lei
- Department of Hepatobiliary Surgery, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, 400000, China
| | - Jiaguo Wang
- Department of Hepatobiliary Surgery, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, 400000, China
| | - Xingxing Wang
- Department of Hepatobiliary Surgery, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, 400000, China
| | - Hongxiang Wang
- Department of Hepatobiliary Surgery, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, 400000, China
| | - Run Hu
- Department of Hepatobiliary Surgery, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, 400000, China
| | - Huizhi Zhang
- Department of Hepatobiliary Surgery, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, 400000, China
| | - Wei Xu
- Department of Hepatobiliary and Thyroid Surgery, the People's Hospital of Liangping District, Chongqing, 405200, China
| | - Jie Xu
- Department of Hepatobiliary Surgery, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, 400000, China
| | - Ke You
- Department of Hepatobiliary Surgery, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, 400000, China
| | - Zuojin Liu
- Department of Hepatobiliary Surgery, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, 400000, China.
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Role of Surgery for Pancreatic Ductal Adenocarcinoma in the Era of Multidisciplinary Treatment. J Clin Med 2023; 12:jcm12020465. [PMID: 36675394 PMCID: PMC9867067 DOI: 10.3390/jcm12020465] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2022] [Accepted: 01/04/2023] [Indexed: 01/09/2023] Open
Abstract
The incidence and mortality rates of pancreatic ductal adenocarcinoma (PDAC) have increased in recent years worldwide [...].
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Lin Q, Zheng S, Yu X, Chen M, Zhou Y, Zhou Q, Hu C, Gu J, Xu Z, Wang L, Liu Y, Liu Q, Wang M, Li G, Cheng H, Zhou D, Liu G, Fu Z, Long Y, Li Y, Wang W, Qin R, Li Z, Chen R. Standard pancreatoduodenectomy versus extended pancreatoduodenectomy with modified retroperitoneal nerve resection in patients with pancreatic head cancer: a multicenter randomized controlled trial. Cancer Commun (Lond) 2022; 43:257-275. [PMID: 36579790 PMCID: PMC9926959 DOI: 10.1002/cac2.12399] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2022] [Revised: 12/11/2022] [Accepted: 12/14/2022] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND The extent of pancreatoduodenectomy for pancreatic head cancer remains controversial, and more high-level clinical evidence is needed. This study aimed to evaluate the outcome of extended pancreatoduodenectomy (EPD) with retroperitoneal nerve resection in pancreatic head cancer. METHODS This multicenter randomized trial was performed at 6 Chinese high-volume hospitals that enrolled patients between October 3, 2012, and September 21, 2017. Four hundred patients with stage I or II pancreatic head cancer and without specific pancreatic cancer treatments (preoperative chemotherapy or chemoradiation) within three months were randomly assigned to undergo standard pancreatoduodenectomy (SPD) or EPD, with the latter followed by dissection of additional lymph nodes (LNs), nerves and soft tissues 270° on the right side surrounding the superior mesenteric artery and celiac axis. The primary endpoint was overall survival (OS) by intention-to-treat (ITT). The secondary endpoints were disease-free survival (DFS), mortality, morbidity, and postoperative pain intensity. RESULTS The R1 rate was slightly lower with EPD (8.46%) than with SPD (12.56%). The morbidity and mortality rates were similar between the two groups. The median OS was similar in the EPD and SPD groups by ITT in the whole study cohort (23.0 vs. 20.2 months, P = 0.100), while the median DFS was superior in the EPD group (16.1 vs. 13.2 months, P = 0.031). Patients with preoperative CA19-9 < 200.0 U/mL had significantly improved OS and DFS with EPD (EPD vs. SPD, 30.8 vs. 20.9 months, P = 0.009; 23.4 vs. 13.5 months, P < 0.001). The EPD group exhibited significantly lower locoregional (16.48% vs. 35.20%, P < 0.001) and mesenteric LN recurrence rates (3.98% vs. 10.06%, P = 0.022). The EPD group exhibited less back pain 6 months postoperation than the SPD group. CONCLUSIONS EPD for pancreatic head cancer did not significantly improve OS, but patients with EPD treatment had significantly improved DFS. In the subgroup analysis, improvements in both OS and DFS in the EPD arm were observed in patients with preoperative CA19-9 < 200.0 U/mL. EPD could be used as an effective surgical procedure for patients with pancreatic head cancer, especially those with preoperative CA19-9 < 200.0 U/mL.
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Affiliation(s)
- Qing Lin
- Department of Pancreas CenterDepartment of General SurgeryGuangdong Provincial People's HospitalGuangdong Academy of Medical SciencesGuangzhouGuangdongPeople's Republic of China,Department of Pancreatobiliary SurgerySun Yat‐sen Memorial HospitalSun Yat‐sen UniversityGuangzhouGuangdongPeople's Republic of China,Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation Medical Research CenterSun Yat‐Sen Memorial HospitalSun Yat‐Sen UniversityGuangzhouGuangdongPeople's Republic of China
| | - Shangyou Zheng
- Department of Pancreas CenterDepartment of General SurgeryGuangdong Provincial People's HospitalGuangdong Academy of Medical SciencesGuangzhouGuangdongPeople's Republic of China,Department of Pancreatobiliary SurgerySun Yat‐sen Memorial HospitalSun Yat‐sen UniversityGuangzhouGuangdongPeople's Republic of China,Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation Medical Research CenterSun Yat‐Sen Memorial HospitalSun Yat‐Sen UniversityGuangzhouGuangdongPeople's Republic of China
| | - Xianjun Yu
- Department of Pancreatic SurgeryFudan University Shanghai Cancer CenterShanghaiPeople's Republic of China
| | - Meifu Chen
- Hunan Research Center of Biliary Disease/Department of Hepatobiliary SurgeryHunan Provincial People's Hospital/The First Affiliated Hospital of Hunan Normal UniversityChangshaHunanPeople's Republic of China
| | - Yu Zhou
- Department of Pancreas CenterDepartment of General SurgeryGuangdong Provincial People's HospitalGuangdong Academy of Medical SciencesGuangzhouGuangdongPeople's Republic of China
| | - Quanbo Zhou
- Department of Pancreatobiliary SurgerySun Yat‐sen Memorial HospitalSun Yat‐sen UniversityGuangzhouGuangdongPeople's Republic of China,Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation Medical Research CenterSun Yat‐Sen Memorial HospitalSun Yat‐Sen UniversityGuangzhouGuangdongPeople's Republic of China
| | - Chonghui Hu
- Department of Pancreas CenterDepartment of General SurgeryGuangdong Provincial People's HospitalGuangdong Academy of Medical SciencesGuangzhouGuangdongPeople's Republic of China,Department of Pancreatobiliary SurgerySun Yat‐sen Memorial HospitalSun Yat‐sen UniversityGuangzhouGuangdongPeople's Republic of China,Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation Medical Research CenterSun Yat‐Sen Memorial HospitalSun Yat‐Sen UniversityGuangzhouGuangdongPeople's Republic of China
| | - Jing Gu
- Department of Medical StatisticsSchool of Public HealthSun Yat‐sen UniversityGuangzhouGuangdongPeople's Republic of China
| | - Zhongdong Xu
- Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation Medical Research CenterSun Yat‐Sen Memorial HospitalSun Yat‐Sen UniversityGuangzhouGuangdongPeople's Republic of China,Department of AnesthesiologySun Yat‐sen Memorial HospitalSun Yat‐sen UniversityGuangzhouGuangdongPeople's Republic of China
| | - Lin Wang
- Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation Medical Research CenterSun Yat‐Sen Memorial HospitalSun Yat‐Sen UniversityGuangzhouGuangdongPeople's Republic of China,Department of PathologySun Yat‐sen Memorial HospitalGuangzhouGuangdongPeople's Republic of China
| | - Yimin Liu
- Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation Medical Research CenterSun Yat‐Sen Memorial HospitalSun Yat‐Sen UniversityGuangzhouGuangdongPeople's Republic of China,Department of OncologySun Yat‐sen Memorial HospitalSun Yat‐sen University GuangzhouGuangdongPeople's Republic of China
| | - Qingyu Liu
- Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation Medical Research CenterSun Yat‐Sen Memorial HospitalSun Yat‐Sen UniversityGuangzhouGuangdongPeople's Republic of China,Department of RadiologySun Yat‐sen Memorial HospitalSun Yat‐sen UniversityGuangzhouGuangdongPeople's Republic of China
| | - Min Wang
- Department of Biliary‐Pancreatic SurgeryAffiliated Tongji HospitalTongji Medical CollegeHuazhong University of Science and TechnologyWuhanHubeiPeople's Republic of China
| | - Guolin Li
- Department of HepatobiliaryPancreatic and Splenic surgerythe Sixth Affiliated Hospital of Sun Yat‐sen UniversityGuangzhouGuangdongPeople's Republic of China
| | - He Cheng
- Department of Pancreatic SurgeryFudan University Shanghai Cancer CenterShanghaiPeople's Republic of China
| | - Dongkai Zhou
- Hepatobiliary and Pancreatic Interventional Treatment CenterDivision of Hepatobiliary and Pancreatic SurgeryThe First Affiliated HospitalCollege of MedicineZhejiang UniversityHangzhouZhejiangPeople's Republic of China
| | - Guodong Liu
- Department of General SurgeryXiangya HospitalCentral South UniversityChangshaHunanPeople's Republic of China
| | - Zhiqiang Fu
- Department of Pancreatobiliary SurgerySun Yat‐sen Memorial HospitalSun Yat‐sen UniversityGuangzhouGuangdongPeople's Republic of China,Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation Medical Research CenterSun Yat‐Sen Memorial HospitalSun Yat‐Sen UniversityGuangzhouGuangdongPeople's Republic of China
| | - Yu Long
- Department of Pancreatobiliary SurgerySun Yat‐sen Memorial HospitalSun Yat‐sen UniversityGuangzhouGuangdongPeople's Republic of China,Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation Medical Research CenterSun Yat‐Sen Memorial HospitalSun Yat‐Sen UniversityGuangzhouGuangdongPeople's Republic of China
| | - Yixiong Li
- Department of General SurgeryXiangya HospitalCentral South UniversityChangshaHunanPeople's Republic of China
| | - Weilin Wang
- Hepatobiliary and Pancreatic Interventional Treatment CenterDivision of Hepatobiliary and Pancreatic SurgeryThe First Affiliated HospitalCollege of MedicineZhejiang UniversityHangzhouZhejiangPeople's Republic of China,Department of Hepatobiliary and Pancreatic SurgeryThe Second Affiliated HospitalZhejiang University School of MedicineHangzhouZhejiangPeople's Republic of China,Key Laboratory of Precision Diagnosis and Treatment for Hepatobiliary and Pancreatic Tumor of Zhejiang ProvinceHangzhouZhejiangPeople's Republic of China
| | - Renyi Qin
- Department of Biliary‐Pancreatic SurgeryAffiliated Tongji HospitalTongji Medical CollegeHuazhong University of Science and TechnologyWuhanHubeiPeople's Republic of China
| | - Zhihua Li
- Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation Medical Research CenterSun Yat‐Sen Memorial HospitalSun Yat‐Sen UniversityGuangzhouGuangdongPeople's Republic of China,Department of OncologySun Yat‐sen Memorial HospitalSun Yat‐sen University GuangzhouGuangdongPeople's Republic of China
| | - Rufu Chen
- Department of Pancreas CenterDepartment of General SurgeryGuangdong Provincial People's HospitalGuangdong Academy of Medical SciencesGuangzhouGuangdongPeople's Republic of China,Department of Pancreatobiliary SurgerySun Yat‐sen Memorial HospitalSun Yat‐sen UniversityGuangzhouGuangdongPeople's Republic of China,Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation Medical Research CenterSun Yat‐Sen Memorial HospitalSun Yat‐Sen UniversityGuangzhouGuangdongPeople's Republic of China
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5
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Malleo G, Maggino L, Qadan M, Marchegiani G, Ferrone CR, Paiella S, Luchini C, Mino-Kenudson M, Capelli P, Scarpa A, Lillemoe KD, Bassi C, Castillo CFD, Salvia R. Reassessment of the Optimal Number of Examined Lymph Nodes in Pancreatoduodenectomy for Pancreatic Ductal Adenocarcinoma. Ann Surg 2022; 276:e518-e526. [PMID: 33177357 DOI: 10.1097/sla.0000000000004552] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE The aim of this study was to reappraise the optimal number of examined lymph nodes (ELNs) in pancreatoduodenectomy (PD) for pancreatic ductal adenocarcinoma (PDAC). SUMMARY BACKGROUND DATA The well-established threshold of 15 ELNs in PD for PDAC is optimized for detecting 1 positive node (PLN) per the previous 7th edition of the American Joint Committee on Cancer (AJCC) staging manual. In the framework of the 8th edition, where at least 4 PLN are needed for an N2 diagnosis, this threshold may be inadequate for accurate staging. METHODS Patients who underwent upfront PD at 2 academic institutions between 2000 and 2016 were analyzed. The optimal ELN threshold was defined as the cut-point associated with a 95% probability of identifying at least 4 PLNs in N2 patients. The results were validated addressing the N-status distribution and stage migration. RESULTS Overall, 1218 patients were included. The median number of ELN was 26 (IQR 17-37). ELN was independently associated with N2-status (OR 1.27, P < 0.001). The estimated optimal threshold of ELN was 28. This cut-point enabled improved detection of N2 patients and stage III disease (58% vs 37%, P = 0.001). The median survival was 28.6 months. There was an improved survival in N0/N1 patients when ELN exceeded 28, suggesting a stage migration effect (47 vs 29 months, adjusted HR 0.649, P < 0.001). In N2 patients, this threshold was not associated with survival on multivariable analysis. CONCLUSION Examining at least 28 LN in PD for PDAC ensures optimal staging through improved detection of N2/stage III disease. This may have relevant implications for benchmarking processes and quality implementation.
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Affiliation(s)
- Giuseppe Malleo
- Unit of General and Pancreatic Surgery, Department of Surgery and Oncology, University of Verona Hospital Trust, Verona, Italy
| | - Laura Maggino
- Unit of General and Pancreatic Surgery, Department of Surgery and Oncology, University of Verona Hospital Trust, Verona, Italy
| | - Motaz Qadan
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Giovanni Marchegiani
- Unit of General and Pancreatic Surgery, Department of Surgery and Oncology, University of Verona Hospital Trust, Verona, Italy
| | - Cristina R Ferrone
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Salvatore Paiella
- Unit of General and Pancreatic Surgery, Department of Surgery and Oncology, University of Verona Hospital Trust, Verona, Italy
| | - Claudio Luchini
- Department of Pathology and Diagnostics, University of Verona Hospital Trust, Verona, Italy
| | - Mari Mino-Kenudson
- Department of Pathology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Paola Capelli
- Department of Pathology and Diagnostics, University of Verona Hospital Trust, Verona, Italy
| | - Aldo Scarpa
- Department of Pathology and Diagnostics, University of Verona Hospital Trust, Verona, Italy
- ARC-Net Research Center, University of Verona, Verona, Italy
| | - Keith D Lillemoe
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Claudio Bassi
- Unit of General and Pancreatic Surgery, Department of Surgery and Oncology, University of Verona Hospital Trust, Verona, Italy
| | | | - Roberto Salvia
- Unit of General and Pancreatic Surgery, Department of Surgery and Oncology, University of Verona Hospital Trust, Verona, Italy
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Malleo G, Maggino L, Casciani F, Lionetto G, Nobile S, Lazzarin G, Paiella S, Esposito A, Capelli P, Luchini C, Scarpa A, Bassi C, Salvia R. Importance of Nodal Metastases Location in Pancreatoduodenectomy for Pancreatic Ductal Adenocarcinoma: Results from a Prospective, Lymphadenectomy Protocol. Ann Surg Oncol 2022; 29:3477-3488. [PMID: 35192154 PMCID: PMC9072462 DOI: 10.1245/s10434-022-11417-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Accepted: 01/16/2022] [Indexed: 12/04/2022]
Abstract
BACKGROUND Implementing a prospective lymphadenectomy protocol, we investigated the nodal yields and metastases per anatomical stations and nodal echelon following upfront pancreatoduodenectomy (PD) for cancer. Next, the relationship between the extension of nodal dissection, the number of examined and positive nodes (ELN/PLN), disease staging and prognosis was assessed. METHODS Lymphadenectomy included stations 5, 6, 8a-p, 12a-b-p, 13, 14a-b, 17, and jejunal mesentery nodes. Data were stratified by N-status, anatomical stations, and nodal echelons. First echelon was defined as stations embedded in the main specimen and second echelon as stations sampled as separate specimens. Recurrence and survival analyses were performed by using standard statistics. RESULTS Overall, 424 patients were enrolled from June 2013 through December 2018. The median number of ELN and PLN was 42 (interquartile range [IQR] 34-50) and 4 (IQR 2-8). Node-positive patients were 88.2%. The commonest metastatic sites were stations 13 (77.8%) and 14 (57.5%). The median number of ELN and PLN in the first echelon was 28 (IQR 23-34) and 4 (IQR 1-7). While first-echelon dissection provided enough ELN for optimal nodal staging, the aggregate rate of second-echelon metastases approached 30%. Nodal-related factors associated with recurrence and survival were N-status, multiple metastatic stations, metastases to station 14, and jejunal mesentery nodes. CONCLUSIONS First-echelon dissection provides adequate number of ELN for optimal staging. Nodal metastases occur mostly at stations 13/14, although second-echelon involvement is frequent. Only station 14 and jejunal mesentery nodes involvement was prognostically relevant. This latter station should be included in the standard nodal map and analyzed pathologically.
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Affiliation(s)
- Giuseppe Malleo
- Department of Surgery, Dentistry, Gynecology and Pediatrics, Unit of General and Pancreatic Surgery, University of Verona, Verona, Italy
| | - Laura Maggino
- Department of Surgery, Dentistry, Gynecology and Pediatrics, Unit of General and Pancreatic Surgery, University of Verona, Verona, Italy
| | - Fabio Casciani
- Department of Surgery, Dentistry, Gynecology and Pediatrics, Unit of General and Pancreatic Surgery, University of Verona, Verona, Italy
| | - Gabriella Lionetto
- Department of Surgery, Dentistry, Gynecology and Pediatrics, Unit of General and Pancreatic Surgery, University of Verona, Verona, Italy
| | - Sara Nobile
- Department of Surgery, Dentistry, Gynecology and Pediatrics, Unit of General and Pancreatic Surgery, University of Verona, Verona, Italy
| | - Gianni Lazzarin
- Department of Surgery, Dentistry, Gynecology and Pediatrics, Unit of General and Pancreatic Surgery, University of Verona, Verona, Italy
| | - Salvatore Paiella
- Department of Surgery, Dentistry, Gynecology and Pediatrics, Unit of General and Pancreatic Surgery, University of Verona, Verona, Italy
| | - Alessandro Esposito
- Department of Surgery, Dentistry, Gynecology and Pediatrics, Unit of General and Pancreatic Surgery, University of Verona, Verona, Italy
| | - Paola Capelli
- Section of Pathology, Department of Pathology and Diagnostics, University of Verona, Verona, Italy
| | - Claudio Luchini
- Section of Pathology, Department of Pathology and Diagnostics, University of Verona, Verona, Italy
| | - Aldo Scarpa
- Section of Pathology, Department of Pathology and Diagnostics, University of Verona, Verona, Italy
| | - Claudio Bassi
- Department of Surgery, Dentistry, Gynecology and Pediatrics, Unit of General and Pancreatic Surgery, University of Verona, Verona, Italy
| | - Roberto Salvia
- Department of Surgery, Dentistry, Gynecology and Pediatrics, Unit of General and Pancreatic Surgery, University of Verona, Verona, Italy.
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Lee SE, Han SS, Kang CM, Kwon W, Paik KY, Song KB, Yang JD, Chung JC, Jeong CY, Kim SW. Korean Surgical Practice Guideline for Pancreatic Cancer 2021: A summary of evidence-based surgical approaches. Ann Hepatobiliary Pancreat Surg 2022; 26:1-16. [PMID: 35220285 PMCID: PMC8901981 DOI: 10.14701/ahbps.22-009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Revised: 02/17/2022] [Accepted: 02/17/2022] [Indexed: 11/17/2022] Open
Abstract
Pancreatic cancer is the eighth most common cancer and the fifth most common cause of cancer-related deaths in Korea. Despite the increasing incidence and high mortality rate of pancreatic cancer, there are no appropriate surgical practice guidelines for the current domestic medical situation. To enable standardization of management and facilitate improvements in surgical outcome, a total of 10 pancreatic surgical experts who are members of Korean Association of Hepato-Biliary-Pancreatic Surgery have developed new recommendations that integrate the most up-to-date, evidence-based research findings and expert opinions. This is an English version of the Korean Surgical Practice Guideline for Pancreatic Cancer 2021. This guideline includes 13 surgical questions and 15 statements. Due to the lack of high-level evidence, strong recommendation is almost impossible. However, we believe that this guideline will help surgeons understand the current status of evidence and suggest what to investigate further to establish more solid recommendations in the future.
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Affiliation(s)
- Seung Eun Lee
- Department of Surgery, Chung-Ang University College of Medicine, Seoul, Korea
| | - Sung-Sik Han
- Department of Surgery, National Cancer Center, Goyang, Korea
| | - Chang Moo Kang
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Yonsei University College of Medicine, Seoul, Korea
| | - Wooil Kwon
- Department of Surgery and Cancer Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Kwang Yeol Paik
- Division of Hepatobiliary and Pancreatic Surgery and Liver Transplantation, Department of Surgery, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Ki Byung Song
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, University of Ulsan College of Medicine, Seoul, Korea
| | - Jae Do Yang
- Department of Surgery, Jeonbuk National University Medical School, Jeonju, Korea
| | - Jun Chul Chung
- Department of Surgery, Soon Chun Hyang University School of Medicine, Cheonan, Korea
| | - Chi-Young Jeong
- Department of Surgery, Gyeongsang National University School of Medicine, Jinju, Korea
| | - Sun-Whe Kim
- Department of Surgery, National Cancer Center, Goyang, Korea
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Nguyen LT, Do DH, Van Nguyen H, Nguyen KT, Nguyen CD. Lymph Node Characteristics and Short-Term Outcomes for Resectable Pancreatic Ductal Adenocarcinoma in Vietnam: A Retrospective Single-Center Study. Indian J Surg 2022. [DOI: 10.1007/s12262-022-03344-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
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10
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Karunakaran M, Barreto SG. Surgery for pancreatic cancer: current controversies and challenges. Future Oncol 2021; 17:5135-5162. [PMID: 34747183 DOI: 10.2217/fon-2021-0533] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Two areas that remain the focus of improvement in pancreatic cancer include high post-operative morbidity and inability to uniformly translate surgical success into long-term survival. This narrative review addresses specific aspects of pancreatic cancer surgery, including neoadjuvant therapy, vascular resections, extended pancreatectomy, extent of lymphadenectomy and current status of minimally invasive surgery. R0 resection confers longer disease-free survival and overall survival. Vascular and adjacent organ resections should be undertaken after neoadjuvant therapy, only if R0 resection can be ensured based on high-quality preoperative imaging, and that too, with acceptable post-operative morbidity. Extended lymphadenectomy does not offer any advantage over standard lymphadenectomy. Although minimally invasive distal pancreatectomies offers some short-term benefits over open distal pancreatectomy, safety remains a concern with minimally invasive pancreatoduodenectomy. Strict adherence to principles and judicious utilization of surgery within a multimodality framework is the way forward.
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Affiliation(s)
- Monish Karunakaran
- Department of Gastrointestinal Surgery, Gastrointestinal Oncology & Bariatric Surgery, Medanta Institute of Digestive & Hepatobiliary Sciences, Medanta-The Medicity, Gurugram 122001, India.,Department of Liver Transplantation & Regenerative Medicine, Medanta-The Medicity, Gurugram 122001, India
| | - Savio George Barreto
- College of Medicine & Public Health, Flinders University, South Australia, Australia.,Division of Surgery & Perioperative Medicine, Flinders Medical Center, Bedford Park, Adelaide, South Australia, Australia
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11
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Korean clinical practice guideline for pancreatic cancer 2021: A summary of evidence-based, multi-disciplinary diagnostic and therapeutic approaches. Pancreatology 2021; 21:1326-1341. [PMID: 34148794 DOI: 10.1016/j.pan.2021.05.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Revised: 04/20/2021] [Accepted: 05/04/2021] [Indexed: 02/08/2023]
Abstract
Pancreatic cancer is the eighth most common cancer and the fifth most common cause of cancer-related death in Korea. To enable standardization of management and facilitate improvements in outcome, a total of 53 multi-disciplinary experts in gastroenterology, surgery, medical oncology, radiation oncology, radiology, nuclear medicine, and pathology in Korea developed new recommendations that integrate the most up-to-date, evidence-based research findings and expert opinions. Recommendations were made on imaging diagnosis, endoscopic management, surgery, radiotherapy, palliative chemotherapy, and specific management procedures, including neoadjuvant treatment or adjuvant treatment for patients with resectable, borderline resectable, and locally advanced unresectable pancreatic cancer. This is the English version of the Korean clinical practice guideline for pancreatic cancer 2021. This guideline includes 20 clinical questions and 32 statements. This guideline represents the most standard guideline for the diagnosis and treatment of patients with pancreatic ductal adenocarcinoma in adults at this time in Korea. The authors believe that this guideline will provide useful and informative advice.
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12
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Neoadjuvant Treatment Strategies in Resectable Pancreatic Cancer. Cancers (Basel) 2021; 13:cancers13184724. [PMID: 34572951 PMCID: PMC8469083 DOI: 10.3390/cancers13184724] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Revised: 09/15/2021] [Accepted: 09/15/2021] [Indexed: 12/24/2022] Open
Abstract
Simple Summary Only 10–20% of patients with newly diagnosed resectable pancreatic adenocarcinoma have potentially resectable disease. Upfront surgery is the gold standard, but it is rarely curative. After surgical extirpation of tumors, up to 80% of patients will develop cancer recurrence, and the initial relapse is metastatic in 50–70% of these patients. Adjuvant chemotherapy offers the best strategy to date to improve overall survival but faces real challenges; some patients will experience rapid disease progression within 3 months of surgery and patients who do not receive all planned cycles of chemotherapy have unfavourable oncological outcomes. The neoadjuvant approach is therefore logical but requires further investigation. This approach shows favourable trends regarding disease-free survival and overall survival but, in the absence of rigorous published phase III trials, is not validated to date. Here, we intend to provide a comprehensive analysis of the literature to provide direction for future studies. Abstract Complete surgical resection is the cornerstone of curative therapy for resectable pancreatic adenocarcinoma. Upfront surgery is the gold standard, but it is rarely curative. Neoadjuvant treatment is a logical option, as it may overcome some of the limitations of adjuvant therapy and has already shown some encouraging results. The main concern regarding neoadjuvant therapy is the risk of disease progression during chemotherapy, meaning the opportunity to undergo the intended curative surgery is missed. We reviewed all recent literature in the following areas: major surveys, retrospective studies, meta-analyses, and randomized trials. We then selected the ongoing trials that we believe are of interest in this field and report here the results of a comprehensive review of the literature. Meta-analyses and randomized trials suggest that neoadjuvant treatment has a positive effect. However, no study to date can be considered practice changing. We considered design, endpoints, inclusion criteria and results of available randomized trials. Neoadjuvant treatment appears to be at least a feasible strategy for patients with resectable pancreatic cancer.
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13
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Laparoscopic pancreaticoduodenectomy in pancreatic ductal adenocarcinoma. JOURNAL OF MINIMALLY INVASIVE SURGERY 2021; 24:169-173. [PMID: 35600105 PMCID: PMC8977379 DOI: 10.7602/jmis.2021.24.3.169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Revised: 08/24/2021] [Accepted: 08/26/2021] [Indexed: 11/23/2022]
Abstract
Laparoscopic pancreatoduodenectomy (LPD) in pancreatic cancer is primarily criticized for its technical and oncological safety. Although solid evidence has not yet been established, many institutions are performing LPD for pancreatic cancer patients, with continuous efforts to ensure oncologic safety. In this video, we demonstrated a case of standard LPD combined with vascular resection in pancreatic cancer.
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14
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Peparini N. Paraaortic dissection in "total mesopancreas excision" and "mesopancreas-first resection" pancreaticoduodenectomies for pancreatic cancer: Useless, optional, or necessary?A systematic review. Surg Oncol 2021; 38:101639. [PMID: 34375818 DOI: 10.1016/j.suronc.2021.101639] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Revised: 06/21/2021] [Accepted: 08/01/2021] [Indexed: 01/06/2023]
Abstract
The mesopancreas does not have well-defined boundaries but is continuous and connected through its components with the paraaortic area. The mesopancreatic resection margin has been indicated as the primary site for R1 resection after PD in pancreatic head cancer and total mesopancreas excision has been proposed to achieve adequate retropancreatic margin clearance and to minimize the likelihood of R1 resection. However, the anatomy of the mesopancreas requires extended dissection of the paraaortic area to maximize posterior clearance. The artery-first surgical approach has been developed to increase local radicality at the mesopancreatic resection margin. During PD, the artery-first approach begins with dissection of the connective tissues around the SMA. However, the concept of the mesopancreas as a boundless structure that includes circumferential tissues around the SMA, SMV, and paraaortic tissue highlights the need to shift from artery-first PD to mesopancreas-first PD to reduce the risk of R1 resection. From this perspective the "artery-first" approach, which allows for the avoidance of R2 resection risk, should be integrated into the "mesopancreas-first" approach to improve the R0 resection rate. In total mesopancreas excision and mesopancreas-first pancreaticoduodenectomies, the inclusion of the paraaortic area and circumferential area around the SMA in the resection field is necessary to control the tumour spread along the mesopancreatic resection margin rather than to control or stage the spread in the nodal basin.
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Affiliation(s)
- Nadia Peparini
- Azienda Sanitaria Locale Roma 6, Distretto 3, via Mario Calo' 5, 00043, Ciampino (Rome), Italy.
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15
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Extended Venous Resections for Borderline Resectable Pancreatic Head Adenocarcinoma-A Retrospective Studies of Nine Cases. Healthcare (Basel) 2021; 9:healthcare9080978. [PMID: 34442115 PMCID: PMC8392255 DOI: 10.3390/healthcare9080978] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Revised: 07/24/2021] [Accepted: 07/29/2021] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND pancreatic cancer is one of the most lethal malignancies and a leading cause of cancer-related death worldwide. The only chance to improve the long-term outcomes of patients with pancreatic cancer is surgery with radical intent. METHODS in the present paper, we aim to describe a case series of 9 patients submitted to radical surgery for borderline resectable pancreatic cancer. RESULTS in all cases, negative resection margins were achieved. The types of venous resection consisted of tangential portal vein resection in four cases, circumferential portal vein resection with direct reanastomosis in one case and circumferential resection with graft placement in another four cases; postoperatively, one patient developed a vascular surgery-related complication consisting of graft thrombosis and thus necessitated prolonged anticoagulant therapy. CONCLUSIONS extended venous resections can be a safe and efficient way to maximize the benefits of radical surgery in locally advanced, borderline resectable pancreatic cancer.
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16
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Mihaljevic AL, Hackert T, Loos M, Hinz U, Schneider M, Mehrabi A, Hoffmann K, Berchtold C, Müller-Stich BP, Diener M, Strobel O, Büchler MW. Not all Whipple procedures are equal: Proposal for a classification of pancreatoduodenectomies. Surgery 2021; 169:1456-1462. [PMID: 33386130 DOI: 10.1016/j.surg.2020.11.030] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Revised: 11/14/2020] [Accepted: 11/17/2020] [Indexed: 01/27/2023]
Abstract
BACKGROUND Pancreatoduodenectomy is the standard treatment for pathologies of the pancreatic head and is performed routinely worldwide. The aim of the study was to analyze this procedure in terms of extent of surgery, technical difficulty, and clinical outcomes and thereby provide a standardized surgical categorization of pancreatoduodenectomies for future reference. METHODS For this cohort study, all patients who underwent pancreatoduodenectomy at a single center within an 18-year period (October 2001 to December 2019) were identified in a prospectively maintained database. Based on technical difficulty and extent of surgery, 4 pancreatoduodenectomy types were proposed: (1) standard pancreatoduodenectomy; (2) pancreatoduodenectomy with portal vein/superior mesenteric vein resection; (3) pancreatoduodenectomy with multivisceral resection; and (4) pancreatoduodenectomy with arterial resection. Patient characteristics, surgical parameters, and perioperative morbidity and mortality were analyzed. The 4 types were compared with regard to their surgical outcomes. RESULTS A total of 3,953 pancreatoduodenectomies were performed in the study period. Standard pancreatoduodenectomy (type 1) was the most frequent procedure (n = 2,931, 74.1%), followed by pancreatoduodenectomy with portal vein/superior mesenteric vein resection (type 2: n = 568, 14.4%), pancreatoduodenectomy with multivisceral resection (type 3: n = 415, 10.5%), and pancreatoduodenectomy with arterial resection (type 4: n = 39, 1.0%). Demographic baseline characteristics were clinically comparable among pancreatoduodenectomy types. Mortality within 90-days correlated with the type of pancreatoduodenectomy (type 1: 2.9%; type 2: 4.2%; type 3: 6.3%; type 4: 10.3%; P = .0007). Overall surgical morbidity was 41.7% (type 1), 40.8% (type 2), 52.5% (type 3), and 59.0% (type 4) (P < .0001), including postoperative pancreatic fistula type B/C (type 1: 11.9%; type 2: 7.7%; type 3: 14.7%; type 4: 15.4; P = .0031) and delayed gastric emptying (type 1: 19.4%; type 2: 22.5%; type 3: 22.0%; type 4: 25.6%; P = .187) as the most frequent complications. Relaparotomies were more frequent in type 4 (20.5%) and type 3 (20.6%) than in type 2 (12.0%) or type 1 (10.4%) pancreatoduodenectomy (P < .0001). Intensive care unit stay ≥2 days was more frequent in type 4 (48.7%) compared with type 3 (25.7%) or type 2 (27.1%) and type 1 (18.6%) (P < .0001). CONCLUSION The results show different clinical outcomes for the 4 types of pancreatoduodenectomy. Morbidity and mortality correlate with pancreatoduodenectomy type. The proposed pancreatoduodenectomy classification is useful for reporting pancreatoduodenectomy procedures, enhances the comparability of future studies, may be used for training purposes, and may guide intra and postoperative decision-making.
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Affiliation(s)
- Andre L Mihaljevic
- Department of General, Visceral, and Transplantation Surgery, Heidelberg University Hospital, Germany
| | - Thilo Hackert
- Department of General, Visceral, and Transplantation Surgery, Heidelberg University Hospital, Germany
| | - Martin Loos
- Department of General, Visceral, and Transplantation Surgery, Heidelberg University Hospital, Germany
| | - Ulf Hinz
- Department of General, Visceral, and Transplantation Surgery, Heidelberg University Hospital, Germany
| | - Martin Schneider
- Department of General, Visceral, and Transplantation Surgery, Heidelberg University Hospital, Germany
| | - Arianeb Mehrabi
- Department of General, Visceral, and Transplantation Surgery, Heidelberg University Hospital, Germany
| | - Katrin Hoffmann
- Department of General, Visceral, and Transplantation Surgery, Heidelberg University Hospital, Germany
| | - Christoph Berchtold
- Department of General, Visceral, and Transplantation Surgery, Heidelberg University Hospital, Germany
| | - Beat P Müller-Stich
- Department of General, Visceral, and Transplantation Surgery, Heidelberg University Hospital, Germany
| | - Markus Diener
- Department of General, Visceral, and Transplantation Surgery, Heidelberg University Hospital, Germany
| | - Oliver Strobel
- Department of General, Visceral, and Transplantation Surgery, Heidelberg University Hospital, Germany
| | - Markus W Büchler
- Department of General, Visceral, and Transplantation Surgery, Heidelberg University Hospital, Germany.
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17
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Achieving 'Marginal Gains' to Optimise Outcomes in Resectable Pancreatic Cancer. Cancers (Basel) 2021; 13:cancers13071669. [PMID: 33916294 PMCID: PMC8037133 DOI: 10.3390/cancers13071669] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Revised: 03/19/2021] [Accepted: 03/24/2021] [Indexed: 12/21/2022] Open
Abstract
Simple Summary Improving outcomes in pancreatic cancer is achievable through the accumulation of marginal gains. There exists evidence of variation and undertreatment in many areas of the care pathway. By fully realising the existing opportunities, there is the potential for immediate improvements in outcomes and quality of life. Abstract Improving outcomes among patients with resectable pancreatic cancer is one of the greatest challenges of modern medicine. Major improvements in survival will result from the development of novel therapies. However, optimising existing pathways, so that patients realise benefits of already proven treatments, presents a clear opportunity to improve outcomes in the short term. This narrative review will focus on treatments and interventions where there is a clear evidence base to improve outcomes in pancreatic cancer, and where there is also evidence of variation and under-treatment. Avoidance of preoperative biliary drainage, treatment of pancreatic exocrine insufficiency, prehabiliation and enhanced recovery after surgery, reducing perioperative complications, optimising opportunities for elderly patients to receive therapy, optimising adjuvant chemotherapy and regular surveillance after surgery are some of the strategies discussed. Each treatment or pathway change represents an opportunity for marginal gain. Accumulation of marginal gains can result in considerable benefit to patients. Given that these interventions already have evidence base, they can be realised quickly and economically.
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18
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Hwang SH, Park MS. [Radiologic Evaluation for Resectability of Pancreatic Adenocarcinoma]. TAEHAN YONGSANG UIHAKHOE CHI 2021; 82:315-334. [PMID: 36238739 PMCID: PMC9431945 DOI: 10.3348/jksr.2021.0019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Revised: 03/15/2021] [Accepted: 03/17/2021] [Indexed: 11/25/2022]
Abstract
Imaging studies play an important role in the detection, diagnosis, assessment of resectability, staging, and determination of patient-tailored treatment options for pancreatic adenocarcinoma. Recently, for patients diagnosed with borderline resectable or locally advanced pancreatic cancers, it is recommended to consider curative-intent surgery following neoadjuvant or palliative therapy, if possible. This review covers how to interpret imaging tests and what to consider when assessing resectability, diagnosing distant metastasis, and re-assessing the resectability of pancreatic cancer after neoadjuvant or palliative therapy.
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19
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Zizzo M, Tumiati D, Mereu F, Castro Ruiz C, Biolchini F, Zanelli M, Sanguedolce F, Annessi V. Intraoperative lymph nodes status evaluation and lymphadenectomy in pancreaticoduodenectomy: surgical considerations based on the current literature. Minerva Surg 2020; 76:196-198. [PMID: 33179468 DOI: 10.23736/s2724-5691.20.08594-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Maurizio Zizzo
- Unit of Surgical Oncology, Department of Oncology and Advanced Technologies, Azienda USL - IRCCS di Reggio Emilia, Reggio Emilia, Italy - .,University of Modena and Reggio Emilia, Modena, Italy -
| | - David Tumiati
- Unit of Surgical Oncology, Department of Oncology and Advanced Technologies, Azienda USL - IRCCS di Reggio Emilia, Reggio Emilia, Italy
| | - Federica Mereu
- Unit of Surgical Oncology, Department of Oncology and Advanced Technologies, Azienda USL - IRCCS di Reggio Emilia, Reggio Emilia, Italy
| | - Carolina Castro Ruiz
- Unit of Surgical Oncology, Department of Oncology and Advanced Technologies, Azienda USL - IRCCS di Reggio Emilia, Reggio Emilia, Italy.,University of Modena and Reggio Emilia, Modena, Italy
| | - Federico Biolchini
- Unit of Surgical Oncology, Department of Oncology and Advanced Technologies, Azienda USL - IRCCS di Reggio Emilia, Reggio Emilia, Italy
| | - Magda Zanelli
- Unit of Pathology, Department of Oncology and Advanced Technologies, Azienda USL - IRCCS di Reggio Emilia, Reggio Emilia, Italy
| | | | - Valerio Annessi
- Unit of Surgical Oncology, Department of Oncology and Advanced Technologies, Azienda USL - IRCCS di Reggio Emilia, Reggio Emilia, Italy
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20
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Kotb A, Hajibandeh S, Hajibandeh S, Satyadas T. Meta-analysis and trial sequential analysis of randomised controlled trials comparing standard versus extended lymphadenectomy in pancreatoduodenectomy for adenocarcinoma of the head of pancreas. Langenbecks Arch Surg 2020; 406:547-561. [PMID: 32978673 DOI: 10.1007/s00423-020-01999-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Accepted: 09/22/2020] [Indexed: 11/24/2022]
Abstract
PURPOSE To compare baseline demographics, operative, and survival outcomes of randomised controlled trials (RCTs) comparing standard lymphadenectomy versus extended lymphadenectomy in patients undergoing pancreaticoduodenectomy for pancreatic head cancer METHODS: In compliance with PRISMA standards we performed a meta-analysis of baseline demographics, operative, and survival outcomes of RCTs comparing standard lymphadenectomy versus extended lymphadenectomy in patients undergoing pancreaticoduodenectomy for pancreatic head cancer. The uncertainties associated with varying follow-up periods among the included studies were resolved by analysis of time-to-event outcomes. Moreover, we performed trial sequential analysis (TSA) to determine whether the available evidence is conclusive and to assess the risk of type 1 or type 2 errors. RESULTS Overall, 724 patients from 5 RCTs were included. The included populations were comparable in terms of baseline characteristics. There was no difference between standard and extended lymphadenectomy in terms of pancreatic fistula (OR 0.64, P = 0.11), delayed gastric emptying (OR 0.68, P = 0.40), bile leak (OR 0.33, P = 0.06), wound infection (OR 0.53, P = 0.06), abscess (OR 0.83, P = 0.63), total complications (OR 0.73, P = 0.27), postoperative mortality (OR 1.01, P = 0.85), and overall survival (HR 1.10, P = 0.46). TSA suggested that meta-analysis was conclusive with low risk of type 2 error. The results remained consistent through subgroup analyses based on lymph node positive or negative status and studies from the West and East. CONCLUSIONS Robust evidence from randomised controlled trials (Level 1) suggests no difference in postoperative and survival outcomes between standard and extended lymphadenectomy in patients undergoing pancreaticoduodenectomy for pancreatic head cancer. The findings were consistent in patients with positive and negative lymph node status and in studies from the West or East.
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Affiliation(s)
- Ahmed Kotb
- Department of General Surgery, Glan Clwyd Hospital, Rhyl, Denbighshire, UK
| | - Shahab Hajibandeh
- Department of General Surgery, Glan Clwyd Hospital, Rhyl, Denbighshire, UK.
| | - Shahin Hajibandeh
- Department of General Surgery, Sandwell and West Birmingham Hospitals NHS Trust, Birmingham, UK
| | - Thomas Satyadas
- Department of Hepatobiliary and Pancreatic Surgery, Manchester Royal Infirmary Hospital, Manchester, UK
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21
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Baltatzis M, Rodriquenz MG, Siriwardena AK, De Liguori Carino N. Contemporary management of pancreas cancer in older people. Eur J Surg Oncol 2020; 47:560-568. [PMID: 32950314 DOI: 10.1016/j.ejso.2020.08.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2020] [Accepted: 08/10/2020] [Indexed: 12/20/2022] Open
Abstract
As the population of western countries is aging, the number of patients diagnosed with cancer is growing. Therefore older people, more susceptible to develop pancreatic malignancy, will likely represent the prototype of a pancreatic cancer patient in the near future. Diagnostic modalities utilised for younger patients are also applicable for older individuals. There is accumulative evidence that biological age is not an independent factor predicting poor outcome in elderly patients with resectable disease undergoing surgery, however increased postoperative morbidity and mortality within the elderly group has also been reported. Adjuvant chemotherapy should be offered in all patients with good performance status regardless of their age. Palliative measures for unresectable tumours including relief from biliary and duodenal obstruction as well as chemotherapy should be considered in non-frail patients with reasonable life expectancy. Palliative chemotherapy options are FOLFIRINOX or gemcitabine/nab-paclitaxel for patients with good performance status (0-1) and gemcitabine alone for patients with performance status 2-3. The cornerstone for improving the outcomes of the elderly age group is careful patient selection and perioperative optimization of those who have indication for surgery. Patients and their carers should be involved in the decision making process with emphasis on the expected functional recovery after the proposed treatment modality. The presence of geriatricians in the multidisciplinary team meetings is crucial in order to identify the optimal treatment pathway for elderly patients. Geriatric input regarding peri-habilitation pathways to improve surgical outcomes, to decrease mortality and to expedite patients' functional recovery is highly recommended.
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Affiliation(s)
- Minas Baltatzis
- Regional Hepato-Pancreatico-Biliary Unit, Manchester Royal Infirmary, Manchester University NHS Foundation Trust, Manchester, UK.
| | - Maria Grazia Rodriquenz
- Oncology Unit, Foundation IRCCS, Casa Sollievo della Sofferenza, San Giovanni Rotondo, Italy
| | - Ajith K Siriwardena
- Regional Hepato-Pancreatico-Biliary Unit, Manchester Royal Infirmary, Manchester University NHS Foundation Trust, Manchester, UK
| | - Nicola De Liguori Carino
- Regional Hepato-Pancreatico-Biliary Unit, Manchester Royal Infirmary, Manchester University NHS Foundation Trust, Manchester, UK
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22
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Korrel M, Lof S, van Hilst J, Alseidi A, Boggi U, Busch OR, van Dieren S, Edwin B, Fuks D, Hackert T, Keck T, Khatkov I, Malleo G, Poves I, Sahakyan MA, Bassi C, Abu Hilal M, Besselink MG. Predictors for Survival in an International Cohort of Patients Undergoing Distal Pancreatectomy for Pancreatic Ductal Adenocarcinoma. Ann Surg Oncol 2020; 28:1079-1087. [PMID: 32583198 PMCID: PMC7801299 DOI: 10.1245/s10434-020-08658-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2019] [Indexed: 02/06/2023]
Abstract
Background Surgical factors, including resection of Gerota’s fascia, R0-resection, and lymph node yield, may be associated with survival after distal pancreatectomy (DP) for pancreatic ductal adenocarcinoma (PDAC), but evidence from large multicenter studies is lacking. This study aimed to identify predictors for overall survival after DP for PDAC, especially those related to surgical technique. Patients and Methods Data from an international retrospective cohort including patients from 11 European countries and the USA who underwent DP for PDAC (2007–2015) were analyzed. Cox proportional hazard analyses were performed and included Gerota’s fascia resection, R0 resection, lymph node ratio, extended resection, and a minimally invasive approach. Results Overall, 1200 patients from 34 centers with median follow-up of 15 months [interquartile range (IQR) 5–31 months] and median survival period of 30 months [95% confidence interval (CI), 27–33 months] were included. Gerota’s fascia resection [hazard ratio (HR) 0.74; p = 0.019], R0 resection (HR 0.70; p = 0.006), and decreased lymph node ratio (HR 0.28; p < 0.001) were associated with improved overall survival, whereas extended resection (HR 1.75; p < 0.001) was associated with worse overall survival. A minimally invasive approach did not improve survival as compared with an open approach (HR 1.14; p = 0.350). Adjuvant chemotherapy (HR 0.67; p = 0.003) was also associated with improved overall survival. Conclusions This international cohort identified Gerota’s fascia resection, R0 resection, and decreased lymph node ratio as factors associated with improved overall survival during DP for PDAC. Surgeons should strive for R0 resection and adequate lymphadenectomy and could also consider Gerota’s fascia resection in their routine surgical approach. Electronic supplementary material The online version of this article (10.1245/s10434-020-08658-5) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- M Korrel
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - S Lof
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands.,Department of General Surgery, Instituto Ospedaliero Fondazione Poliambulanza, Brescia, Italy
| | - J van Hilst
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands.,Department of Surgery, OLVG Oost, Amsterdam, The Netherlands
| | - A Alseidi
- Division of Hepatopancreatobiliary and Endocrine Surgery, Virginia Mason Medical Center, Seattle, WA, USA
| | - U Boggi
- Division of General and Transplant Surgery, University of Pisa, Pisa, Italy
| | - O R Busch
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - S van Dieren
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - B Edwin
- Department of HPB Surgery, The Intervention Center, Institute for Clinical Medicine, Oslo University Hospital, Oslo, Norway
| | - D Fuks
- Department of Surgery, Institut Mutualiste Montsouris, Paris, France
| | - T Hackert
- Department of Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - T Keck
- Department of Surgery, University Hospital Schleswig-Holstein, Campus Lübeck, Lübeck, Germany
| | - I Khatkov
- Department of Surgery, Moscow Clinical Scientific Center, Moscow, Russian Federation
| | - G Malleo
- Department of Surgery, Pancreas Institute, Verona University Hospital, Verona, Italy
| | - I Poves
- Department of Surgery, Hospital del Mar, Barcelona, Spain
| | - M A Sahakyan
- Department of HPB Surgery, The Intervention Center, Institute for Clinical Medicine, Oslo University Hospital, Oslo, Norway.,Department of Surgery N1, Yerevan State Medical University After M. Heratsi, Yerevan, Armenia
| | - C Bassi
- Department of Surgery, Pancreas Institute, Verona University Hospital, Verona, Italy
| | - M Abu Hilal
- Department of General Surgery, Instituto Ospedaliero Fondazione Poliambulanza, Brescia, Italy.
| | - M G Besselink
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands.
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